I was once greeted at the home of a young woman named Lia who was bedridden since her recent delivery. The narrow, uneven staircase leading to her 3-piece apartment, on the second floor immediately struck me. Three plastic chairs and some dusty decorations adorned the living room. I was climbing the shaky staircase when her husband Manno appeared to welcome me. The couple was forced to marry 4 years prior, to escape public shaming when Lia unexpectedly became pregnant with their first daughter Zina. Zina was inside, busy undoing her braids. She was so unusually calm and silent that Manno asked her if everything was alright, with a strong smell of alcohol on his breath. Although she appeared serene, in reality, she was feeling like her world was crumbling ever since her mother, Lia, gave birth to her little sister, since then Lia’s behavior had started to change.

Manno led me into the bedroom where Lia was resting. A dirty-white mosquito net covered the bed. Children toys and elementary school books stood on cupboards and small tables. I quickly understood that the entire family was living in the same small space. Lia stared aloofly at the ceiling. The newborn girl was laying down to her left. While Manno was getting me a chair, I noticed how Lia dropped quick frightened glances towards the baby from time to time. As Manno entered the room again staring down, ashamed, Lia uttered insulting and incoherent words and even threatened to choke her own newborn baby. Manno instantly presented his deepest apologies to me, for his wife’s delirium. But I wasn’t surprised at all because I am familiar with such symptoms- confusion, paranoia, agitation, hallucinations and sleeplessness– evocative of a post-partum psychosis, which is a psychiatric illness affecting some women after delivery.

Friends and family think that jealous neighbors took advantage of Lia’s pregnancy to cast a spell on her. Her father has even proposed that she travel to the North of Haiti to find him, to try to ward off this miserable fate. In the northern town where Lia’s father lived, he was very respected thanks to his land, livestock and his expertise in traditional medicine, despite his proclaimed Christian beliefs. Manno informed me that even the doctor they contacted in Port-au-Prince had recommended they go visit a hougan, a Vodou priest that sometimes serves as healer. It is difficult to be clear about the impact of traditional or religious practices on mental illnesses (especially if these diseases are observed from the perspective of Western medicine, as in my case), but I am, nonetheless, aware that they are often the only resource for people suffering from such diseases in Haiti, especially in remote areas. And, Lia or her entourage’s interpretation of her disease, whether it may sound irrational to you or not, is already a step towards treatment. How she understands her disease is important to her healing. If she thinks it is a supernatural misfortune, her caregiver should not disregard her conception.

However, in my mind there was no supernatural misfortune. Unwanted pregnancy, a history of chronic major depressive disorder or depression during pregnancy remain factors that make many women vulnerable to mental illness after childbirth. In fact, although these factors are numerous (biological, psychological and social), in Lia’s case, the living conditions were the most likely cause. Many stressors in her life as a Haitian woman, as a wife, as a mother, as an employee, were always present prior to her pregnancy, but were perhaps seen as isolated situations that have all now bubbled to the surface. Many Haitians are fragmented in this way, as sections of their history are separated but yet unknowingly linked, and can be a source for many ailments.

To provide some context: poverty affects more than 80% of the Haitian population and social exclusion and alienation often go hand in hand. Despite counting for 56% of the population, women are too often denied the most basic rights. When it comes to mental health, such a context is hardly favorable. Opportunities for prosperity are available to the few who have had access to the right education, those who can take advantage of a broken system and the very few born within a supportive environment. On the other hand, elements that could promote resilience and health, such as family support, are rare or poorly integrated.

But, in Haiti, the relationship with mental illnesses is difficult even among the more privileged. No matter the systems of thought, traditional or modern, most of the times, patients are simply dismissed as “mad” or possessed by an evil spirit, regardless of the mental illness the individual suffers from. Local obstetricians (in case of pregnancy-related mental illnesses) and mental health professionals, psychiatrists and psychologists, struggle to address the most pressing health issues concerning women. Numerous medical NGOs also support maternal health in Haiti. But while they often heal the body, mostly focusing on communicable diseases, the mind is highly overlooked. So women usually don’t freely express their real preoccupations and needs, reinforcing the barriers to proper care.

The last time I asked after Lia, she had joined her father’s lakou in the North and was taking pills prescribed by a psychiatrist while simultaneously going through mystical treatment. I was happy to hear that she was doing better. That was good news for her baby. But as I said goodbye to Manno and he replied, the scent of his breath reminded me of someone I had forgotten to ask about. “How’s Zina doing, by the way?” I asked as memories of her sad face resurfaced. – “She’s doing good replied Manno, she’s at school right now, I took her this morning. With Lia gone, I’m the one taking care of her” he added. I nodded with the largest smile I could muster and told him our traditional. “ankouraje.” But I left with a heavy heart, full of fear and prayer for Zina.

In 2006, I spent my first night in Gonaives during a trip from Port-au-Prince. Hurricane Anna and Ike were two years away from burying the city under water one more time. All I knew about Gonaives at the time was its historical significance as the site of the very first declaration of Haiti’s Independence. But after participating in a recent study on cholera in Gonaives, I have gotten a clearer image of not only the city, but of the impact of climate change on urban development, and its consequences on healthcare accessibility. I believe traditional medicine can help reduce this problem.

Gonaives is Haiti’s third most populated city, sheltering 356,324 people as of 2015. According to ESA Consultance’s recent study (which I contributed to), Gonaives is at an important crossroad for commerce from the northern region of the country towards Port-au-Prince, the capital. The concentration of public services in the city attracts people from all over Haiti. Despite its demographic and geographic importance, Gonaives is infamously vulnerable and weak in the face of natural disasters.

In the 1970s, many countryside citizens began moving to urban centers to work in the then booming manufacturing industry. Although population movement continues to happen, employment is not its only guiding force. According to the International Organization for Migration, rural-urban movements in Haiti are often due to environmental events. My experience in Gonaives taught me how climate change contributes to inflate the city’s population.

People who live in vulnerable areas in dry seasons move up to the hills, in neighborhoods in the periphery of Gonaives, to be safe from floods during the rainy seasons. The impact of hurricanes Hanna and Ike in 2008 influenced Gonaives’ population increase and even forced the emergence of new neighborhoods. The city’s population almost doubled from 2003 to 2015. As a matter of fact, between 1954 and 2012, no less than 19 major hurricanes have affected Haiti. Due to persistent vulnerabilities and fiercer hurricane seasons (maybe due to warmer temperatures), such disasters will continue to haunt us. With category 5 hurricane Irma currently approaching Haiti, vulnerable populations are still ill-prepared. How does this affect population health?

As cities expand, services such as clean water, sanitation, and healthcare become less accessible, since the existing structures fail to match the growing demand. In a 2000 national survey in Haiti, they determined that a large number of people consult traditional healers when they are sick before they turn to a physician, because of the former’s proximity to the people. Trends in drugs sale in cities like Port-au-Prince show that most drugs are available over the counter and sold in the streets. Self-medication is also an essential option for Haitians when it comes to treating an ailment. Leveraging self-medication to bridge the gap in healthcare accessibility is not the answer. However, traditional medicine might be worth considering, as it is already playing an important role in the care system in general, particularly in the work being done to eliminate cholera.

Let me explain through an anecdote. Most traditional healers, like one middle-aged woman whose presentation on a panel I recently listened to, draw a line between what she called “natural cholera” and one they consider “mystical.” According to her, “mystical cholera” is mild diarrhea that lasts a few days unlike “natural cholera” which kills within hours if left untreated. When people come to a Lakou or Vodou temple for treatment for “mystical cholera,” the mambo said, they are treated with starch, molasses, and a little nutmeg. If this does not improve the person’s condition, they refer him/her to the closest hospital or health center. In my professional opinion, mystical cholera does not actually exist, but the natural remedies used to treat it are perfectly suitable for healing many kinds of diarrhea. Fortunately, most healers know how to recognize symptoms of actual cholera, provide first aid and oral rehydration and redirect people to cholera treatment centers.

The lesson here is that as a part of the healthcare system in Haiti, traditional healers can leverage their know-how regarding natural treatment and their proximity to a large part of the population to improve access to care. But the department of pharmacopeia and traditional medicine of the Ministry of Health needs to do more extensive work, by surveying and training the traditional healers and promoting their expertise locally. But, being a tradition rather than a formal profession, traditional medicine could pose some challenges as the practices are not backed by a uniform and evidence-based science.

Given the continuing increase in global temperature, it would be delusional to imagine Haitian cities less vulnerable to natural disasters as they continue to expand. Haiti signed the Paris agreement, which propels initiatives to empower peasants and fight the effects of climate change. Therefore, despair is unnecessary. As stated on a lotto stand during one of my visits, we need to prepare for tomorrow Panse ak demen. Climate change will continue to disrupt our society and the accessibility of health care. This liability can be turned into an opportunity to build upon the knowledge and position of traditional healers to close the gap. Traditional medicine and community members can be among the most important steps towards progress.

Published on Woy magazinebefore Hurrinace Irma hit Haiti on September 7, 2017

My brother Keddy and I grew up in Karenaj, a then hassle-free neighborhood in the world-renowned city of Cap-Haitien. Although our family had relatives in Saint-Michel de l’Attalaye, an Artibonite county south of Cap-Haitien, we lived far removed from rural Haiti, except for a few sporadic trips to “andeyò” which is the term Haitians use to refer to rural areas. It’s a Kreyòl word derived from the french “en dehors” translated as outside. So my twin and I, we were raised unfamiliar with most traditional food and to a greater extent, the language and culture of Haiti’s rural regions with their complexity and richness.

When our grand-mother passed away, I could feel that the few stories of Saint-Michel along with anecdotes of our elderly’s rural trips had also vanished. But now, as adults and doctors, we’ve managed to visit the entire country apart from Grand-Anse, either during professional endeavors or on personal adventures. As far as we could tell, decades later, differences still persist between how us, city-raised gentlemen, perceive and express reality and how rural populations do. Not only the rhetoric differs but the very elements of culture struggle to collide. During our trips, those gaps even impaired our ability to communicate with the locals. In terms of local tourism, this situation wouldn’t be much of an issue. But consider the heavy toll of such discrepancy when it comes to patients explaining their symptoms or when it comes to us doctors communicating health risks and treatment options.

In the 1970s, as Haiti’s agriculture sector plummeted, people massively moved from rural regions to adjacent towns in search of a better life. Throughout the decades, the dynamics of rural exodus have only made this transit skyrocket. More than half of Haiti’s population now live in cities. Needless to say that the emigrants carry what they have accumulated as a cultural background with them. The vacuum left by such demographic movement and social context leaves the rural areas very vulnerable. Which in turn often leads to city dwellers, with their own culture, to commute to rural areas for work-related projects, many of them provided by NGOs. This is how we found ourselves on a day-to-day journey trying to comprehend each other.

In rural populations, overcoming issues such as academic illiteracy or comprehending the beliefs in magico-spiritual forces is often a pre requisite for creating rapport and therefore to have impact on a patient’s health outcome. But some other concerns are subtler. I recall having examined an old woman named Annia in Saint-Antoine, a neighborhood next to Poupelard avenue, in Lalue, Port-au-prince. The old woman was from the South and had settled in Saint-Antoine less than 2 years prior to her consultation. Visibly uncomfortable, she described her pain to me in those words: as if a stack of millet was being pounded upon with a big pestle. She made it clear: – “The big ones Doc, not the small ones”. Coffee is very much engrained in every Haitian’s life and I’m very familiar with scenes of people pounding coffee roasts in big pestles, it happens in rural zones as in certain towns, but I sure had no idea as to what it feels like. And can’t obviously make the difference between the big and smaller ones, except for their size. While I was expecting her to describe her symptoms using my words, she relied on images of her daily life. As she spoke, even though we speak the same language, I could feel the gap between us widen and as if we were losing each other.

Keddy has also experienced such “language barrier” when he asked a patient from a locality near Montrouis, when she’d last had her period and she casually replied: – “On the last moon”. While he was anticipating an exact date, ignoring when the last moon was or even what that actually means.

It’s not a mere matter of language (French versus Kreyòl) as the concern is raised ad nauseum but instead a collusion between two different cultures, impairing understanding and proper health communication between two people speaking the same language.

These cultural barriers to communication stress the difficulties to assess and address health risks in patients and communities alike. I remember visiting Maniche with a team of Port-au-prince-based health agents. Most of them were hailed from this very Southern locality, and although our job was to raise concern about the safety of a water source, because they used to drink it and were actually baptized in these waters in their youth, it became harder for them to question its quality. The same goes for patients suffering from high blood pressure who dismiss any change in the way they prepare food because they’ve been taught a particular way by a parent since they were kids. Habit is more powerful than science and without the psychological tools of social and behavioral change communication the work of healthcare providers might as well be for naught.

I went back to Karenaj recently. As I sat in furniture that feel older than the city itself, I was thinking that until we reduce the gap between urban and rural realities we will not be able to understand each other, recognize what puts us at risk and heal our common evils. As I thought of my conversation with Annia and the way many pride themselves as educated, I asked myself if we were hardly doing any good. What good is a doctor’s vast knowledge if he can’t even understand his patient, let alone help her improve her behavior? There is not a single way to resolve these differences. But if we at least stop considering distance as difference, maybe we can start learning and improving together.

I still remember that November morning, Moise Street in Petion-ville was under reconstruction. Dust filled the air and provoked my nose to sneeze multiple times. It was my first day of work as a doctor in Jalouzi. I decided to walk to get there; that was my way of getting to know this colorful neighborhood I knew very little about. All I had in mind were my brother’s quips likening Jalouzi to Kabul by day and New York City by night.

Jalouzi is an impoverished, overpopulated neighborhood, or what the international media would call a slum, in Port-au-Prince with countless houses stacked on top of each other. It is not unlike many other neighborhoods in places like Carrefour feuilles, Carrefour, la plaine etc. The only thing special about Jalouzi is its proximity to Petion-Ville. The view from Petion-Ville’s hotels and bustling restaurants occupied by tourists, expats and the wealthy is none other than the stacked houses of Jalouzi. Ever since the beginning of Jalouzi en couleurs, a government project to paint the houses of Jalouzi in bright colors, a couple of years prior, the slum had caught the world’s attention. So my heart was filled with excitement to experience this side of Haitian life. Almost a year after my experience there, the memories are still vivid in my mind. Yet Jalouzi remains the media’s cherished story, to the extent that RYOT has recently shot a 5-minute documentary short called “The Painter of Jalouzi” for the release of the iPhone 6S Plus of the mega brand Apple. Much to my disappointment, the movie conveys a good bit of misinformation and heavily clashes with the daily reality of Jalouzi.

It took a visit to the archives of Petion-ville’s Town Hall and to the bureau of the civil protection while researching for a book I am writing about Jalouzi to learn that nobody knows the exact number of people actually living there. I realized then that while the bright colors provided the slums with more visibility, the people remained invisible to the State. The people of Jalouzi welcomed the Jalouzi en couleurs government project simply because these people have nothing; they have no choice but to welcome whatever is offered to them. It is no surprise then, that for many of the patients I discussed the project with, healthcare and running water would have been their top priorities if they were given a choice.

Along the Stenio Vincent street in Jalouzi, three health care centers could be counted as of December 2014. But since my first visit, the one that belongs to the Ministry of Health has been closed. Today, its driveway is occupied by vendors, making it difficult to even be noticed. One of the private centers has packed up and the building has been rented to other businesses. Yet the need for healthcare itself has not diminished one bit. On the contrary, in the midst of this situation, various illnesses have arised. Why? Because poverty leaves people extremely vulnerable.

There is no reliable running water in Jalouzi. On the days I reached Jalouzi by foot, I climbed along the slippery steep stairs where women and children carry buckets of water on their heads. Unfortunately, they can only get this water from trucks with water tanks that come once or twice a week, depending on how business is. In the rainy season, there is no clear distinction between the trash and the walkways. Therefore, the soles of people’s feet become public transport for germs which end up straight inside their homes, the stacks of chaotic construction. In the marketplace, food is sold on the floor, meat is covered with flies, the sanitation conditions are dire and precarious.

A mother confessed one day, in the examination room: “All the problems I have go beyond the bright color of my house.” As her issues accumulated, she ran out of money to pay the rent, solely relying on family based in the United States. Her problems, which are closer to the rule rather than the exception, could not be alleviated nor transformed by a paint job. Just as her constant headache did not go away with the makeup she wore that day. Throughout its narration, RYOT’s documentary depicts a delusional image of what life is in Petion-ville’s Jalouzi, which is far from being Haiti’s largest slum, contrary to what they report. Its transformation is only superficial, and the ultimate beneficiaries remain the spectators, foreigners or locals, enjoying the view of Jalouzi’s brightly painted houses from a distance.

In spite of its worldwide reach, “The Painter of Jalouzi” has failed to call for real transformation in people’s lives. To be more accurate, the short film might as well had depicted the real painter of Jalouzi as an outsider. Someone far from the reality of the neighborhood, working in the slums during the day, and returning to relax in his suite at the Royal Oasis Hotel in Petion-Ville at night. This is a missed opportunity to raise awareness on the very real issues of healthcare, education, clean water, energy and human dignity. The government’s Jalouzi en Couleurs project has failed the people of Jalouzi. Why don’t we build schools in the name and memory of Préfète Duffault? Why don’t we push the Ministry of Health reopen its health center? Does it help to apply lipstick to a pig, or to disguise the misery and hunger of the most vulnerable? By blinding ourselves from the suffering of others, one day we might end up being the victims of our own farce.